I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

Summary: New technologies take time to mature, but Gartner’s annual hype cycle diagram provides a guide to whether they are being overhyped and how close they are to becoming productive. http://zd.net/1c2wvEb

The 2013 edition of Gartner’s long-running Hype Cycle for Emerging Technologies focuses on “the evolving relationship between humans and machines … due to the increased hype around smart machines, cognitive computing and the Internet of Things.”

Gartner fellow Jackie Fenn, who came up with the hype cycle idea in 1995, says “there are actually three main trends at work. These are augmenting humans with technology — for example, an employee with a wearable computing device; machines replacing humans — for example, a cognitive virtual assistant acting as an automated customer representative; and humans and machines working alongside each other — for example, a mobile robot working with a warehouse employee to move many boxes.”

Fenn’s collaborator Hung LeHong says these trends have been made possible because machines are becoming better at understanding humans and humans are becoming better at understanding machines. “At the same time, machines and humans are getting smarter by working together.”

Robots have been used on the factory floor for decades but improvements in technology mean there is still plenty of scope for automating both physical and mental procedures. Gartner says: “Organizations should look to some of these representative technologies for sources of innovation on how machines can take over human tasks: volumetric and holographic displays, autonomous vehicles, mobile robots and virtual assistants.”

3. Humans and machines working alongside each other

Gartner says: “The main benefits of having machines working alongside humans are the ability to access the best of both worlds (that is, productivity and speed from machines, emotional intelligence and the ability to handle the unknown from humans). Technologies that represent and support this trend include autonomous vehicles, mobile robots, natural language question and answering, and virtual assistants.” One example is IBM’s Watson working alongside doctors and providing natural-language question answering (NLQA).

The point of the Hype Cycle is to give enterprises some idea how far various technologies are from the “plateau of productivity” where they can be more easily adopted. The cycle has five stages, for which Gartner uses terminology reminiscent of John Bunyan’s Pilgrim’s Progress. It starts with a Technology Trigger: a new invention or innovation. That gets the attention of the media, analysts, conference organizers etc, which drives the idea to a Peak of Inflated Expectations. At this point, disillusion sets in. As I noted in the Guardian in 2005, “The press, having overhyped it, knocks it for being overhyped, and it descends into the Trough of Disillusionment.” Successful innovations pass through the trough and start to climb the Slope of Enlightenment before reaching the Plateau of Productivity.

In the 2013 hype cycle, Technology Triggers include SmartDust, brain-computer interfaces, and quantum computing, all of which Gartner reckons are 10 years or more from the plateau. It reckons autonomous vehicles and biochips are 5-10 years away.

Gartner’s Hype Cycle for Emerging Technologies, 2013 ($1,995) “includes a video in which Ms Fenn provides more details”. Fenn and LeHong are also hosting two free webinars at 3pm and 6pm (UK time) on August 21, registration required.

Jack Schofield spent the 1970s editing photography magazines before becoming editor of an early UK computer magazine, Practical Computing. In 1983, he started writing a weekly computer column for the Guardian, and joined the staff to launch the newspaper’s weekly computer supplement in 1985. This section launched the Guardian’s first website and, in 2001, its first real blog. When the printed section was dropped after 25 years and a couple of reincarnations, he felt it was a time for a change….

How the healthcare industry’s scare tactics have screwed up our economy — and our future http://bit.ly/18TFCaf

There are multiple lines of evidence that doing more things to patients doesn’t always result in better health. I summarize a few examples here.

Dartmouth Studies

Researchers at Dartmouth University examined the relationship between medical resources used and the resulting health outcomes in people nearing the end of their lives in two California regions, Los Angeles and Sacramento.

In Los Angeles, the patients used 61% more hospital beds, 128% more intensive care unit (ICU) beds, and 89% more physician labor in the management of chronically ill patients during the last two years of life compared to Sacramento. In spite of this intense use of medical resources, the quality of care for patients with heart attacks, heart failure, and pneumonia was worse in Los Angeles. Patients did not enjoy this aggressive care either. Patients rated 57% of Los Angeles hospitals as below average compared to 13% of Sacramento hospitals.

What are the cost implications of the overly aggressive care in Los Angeles? If the Los Angeles hospitals had functioned at the same level as the Sacramento hospitals over the five years of the study measuring these differences, the savings to the Medicare system would have been approximately $1.7 billion.

Brain Aneurysms

Researchers studied immediate family members of patients who had symptomatic brain aneurysms. The researchers wanted to know if finding and surgically fixing aneurysms in the healthy family members who had no aneurysm symptoms would prevent strokes and deaths. The results were basically that many people were injured as a result of the surgery, which the researchers didn’t feel justified the few saved lives.

The Medical Outcomes Studies

In the late 1980s and early 1990s a series of studies called the Medical Outcomes Studies were completed. Their purpose was to measure differences in medical resources used and health outcomes in patients with common conditions who saw different kinds of doctors. They wanted to know if ologist care led to better health compared to primary care, and how the doctors differed in practice styles. The researchers studied patients with high blood pressure and diabetes.

For high blood pressure, patients of cardiologists had more office visits, more prescriptions, more lab tests per physician visit, and were more likely to be hospitalized. There was no difference between the three physician types for average blood pressure, complications, or physical function.

For diabetes, patients of endocrinologists were found to have higher hospitalization rates, more office visits, more prescription drugs, and more lab tests per physician visit than family physicians. There was no difference between the three physicians for average sugar levels, physical functioning, and almost all diabetic complications.

Summary

These are just a few examples of how more aggressive medical care doesn’t always result in better health. All of the GIMeC members typically support the notion that more is better. Overcoming this aggression bias will be one of our big challenges in reforming our healthcare system.

(Reuters Health) – Close to one-quarter of colonoscopies performed on older adults in the U.S. may be uncalled for based on screening guidelines, a new study from Texas suggests.

Researchers found rates of inappropriate testing varied widely by doctor. Some did more than 40 percent of their colonoscopies on patients who were likely too old to benefit or who’d had a recent negative screening test and weren’t due for another.

Guidelines from the U.S. Preventive Services Task Force, a government-backed panel, recommend screening for colon cancer – every 10 years, if it’s done with colonoscopy – between age 50 and 75.

After that point, “It involves an unnecessary risk with no added benefit for these older patients,” said Kristin Sheffield, the new study’s lead author from the University of Texas Medical Branch in Galveston.

Those risks include bowel perforation, bleeding and incontinence, as well as the chance of having a false positive test and receiving unnecessary treatment.

Even for screening tests that are universally recommended for middle-aged adults, the balance of benefits and risks eventually points away from screening as people age. Any cancers that are caught might never have shown up during a patient’s lifetime if the person is too old or the cancer too slow-growing.

But because there has been so much effort to educate the public about reasons to get screened, the potential harms are often overlooked – and the idea of stopping screening isn’t regularly discussed, researchers said.

Sheffield and her colleagues looked at Medicare claims data for all of Texas and found just over 23 percent of colonoscopies performed on people age 70 and older were possibly inappropriate.

For patients age 76 to 85, as many as 39 percent of the tests were uncalled for, the researchers wrote Monday in JAMA Internal Medicine. The rest were likely done for diagnostic purposes.

A MORAL OBLIGATION?

Another study published in the same journal supports the idea that many Americans are so focused on the possible benefits of screening that they don’t realize harms are involved as well.

Dr. Alexia Torke from the Indiana University School of Medicine in Indianapolis and her colleagues surveyed 33 adults between age 63 and 91 and found many saw screening as a moral obligation.

Few of the older adults had discussed the possibility of stopping routine screening, such as for breast cancer, with their doctor, and some told the researchers they would distrust or question a doctor who recommended they stop.

“There’s very limited data for any cancer test that it leads to any benefit for older adults,” said Dr. Mara Schonberg, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

“You want to be doing this thinking it’s going to be helping you live longer,” she told Reuters Health – especially because the chance of suffering side effects from screening or treatment may be higher among older people.

Schonberg, who wrote a commentary on Torke’s study, said time spent unnecessarily screening older adults may take away from conversations that could actually benefit their health – such as about exercise and eating better.

“There’s really a strongly held belief that you need to get screened, that it’s irresponsible if you don’t,” said Dr. Steven Woloshin, who has studied attitudes toward screening at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

“There have been all these messages for years about the importance of screening that people have been inundated with, and I think it’s really hard to change the message now, even though it’s become clear that screening is a double-edged sword,” Woloshin, who wasn’t involved in the new research, told Reuters Health.

The researchers agreed screening should be an individual decision as people get older, but that everyone should fully understand what they stand to gain – if anything – and what they could lose by getting screened.

For colon cancer in particular, Sheffield recommended elderly people who really want to be screened go with a less-invasive method than colonoscopy, such as fecal occult blood testing.

OVERUSING ANESTHESIA?

In another analysis of Medicare beneficiaries undergoing colonoscopy, researchers led by Dr. Gregory Cooper from Case Western Reserve University in Cleveland learned the proportion of procedures using anesthesia – most likely propofol – increased from less than nine percent in 2000 to 35 percent in 2009.

The cost of a procedure using anesthesia is about 20 percent higher than one without it, the researchers noted.

Patients in their study suffered a complication – including perforation or breathing problems – during one in 455 procedures using anesthesia, compared to one in 625 without anesthesia. The researchers said so-called deep sedation may impair patients’ airway reflexes and blunt their ability to respond to procedure-related pain.

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland. This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test. –oma is the suffix used in the name of any tumor or enlargement. Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen. Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.

Small ovarian cysts seen on pelvic ultrasound. The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern. Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.

Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors. They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.

Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing. The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests. When abnormal these are usually repeated along with testing for viral hepatitis C and B. If they remain abnormal liver imaging, sometimes liver biopsy are often done. The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight. This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

The NIHR Health Technology Assessment (HTA) Programme is celebrating its impact in clinical and public health research by holding a milestone conference on 9-10 October 2013 in central London.

The emphasis of the conference will be to:

Examine the impact, nationally and internationally of the programme in clinical effectiveness research

Consider the influence of the HTA Programme within the NHS and on UK clinical research

This event celebrates the contribution made by the HTA Programme to the NIHR mission to improve the health and wealth of the nation. It will raise the national and international awareness and prestige of the programme, its projects and published research findings.

In conjunction with the conference The Lancet will be publishing a themed issue on clinical effectiveness research.

On February 21st, seventeen medical specialty societies announced new lists of things physicians and patients should question as part of the ABIM Foundation’s Choosing Wisely campaign. This marks the second release of lists from the campaign; at least 18 societies will release new lists later in the year.

In addition to the announcement of new lists, Consumer Reports—which has worked with the medical specialty societies to create patient-friendly translations—published new brochures that now cover more than 30 specific topic areas.

The National Business Coalition on Health and Pacific Business Group on Health also unveiled new a Choosing Wisely Employer Toolkit to help employers educate their employees about steps they can take to avoid overused or unnecessary tests or procedures.

The announcement of new society lists was covered widely in the media and inspired reactions ranging from cautiously optimistic to skeptical that the campaign could achieve its goals.

A brief sampling:

The New York Times’ The New Old Age BlogFor the Elderly, Medical Procedures to Avoid
“It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments. It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify ‘Five Things Physicians and Patients Should Question.’”

Huffington PostChoosing Wisely, Indeed
“This long overdue and welcome effort is launched to inspire conversations between patients and doctors about the necessity—or lack thereof—of many commonly-ordered diagnostic tests and medical approaches.”

Modern HealthcareCurbing Overuse (subscription required)
“We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Dr. Blair Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what’s unnecessary.”

Stand Up For Health Care Blog“Just in Case” Can Mean More Money and No Benefit
“Choosing Wisely is something we can all do to improve our own care and improve our health care system at large.”

Albany HeraldStaff Editorial: More Isn’t Always Better in Medicine
“For American health care to be what it should be, its core has to reside in truthful communication between a patient and the doctor he or she trusts.”

Akron Beacon Journal Editorial: The Doctors’ List of Don’ts
“The premise of Choosing Wisely is that good information, presented in language that the average layman can grasp, will lead to intelligent conversation and good decisions about appropriate treatment. The project is appealing as an ongoing exercise in determining what is worth the money in medical care. It is especially appealing because when the recommendations come from practitioners themselves, it helps to strip a sensitive discussion of the toxic exaggerations so often the currency of the political arena.”

The Economist: Democracy in America Waste Lots, Want Lots
“The Choosing Wisely campaign is bravely entering the fray, but its ambition is modest. It hopes to convey that not all care is good care. Slowly, the culture among physicians and patients may change. But the campaign has no teeth. Its suggestions are phrased in the gentlest possible manner, listing treatments that ‘patients and physicians should question.’”

At the end of the 1960s, the then US surgeon general William H Steward famously declared: “The war against infectious diseases has been won.” His optimism might well have been justified at the time. The discovery of antibiotics and their widespread introduction had transformed both medical practice and life expectancy.

Antibiotics still transform lives, but—as with so many of the world’s resources—we now know that they are not limitless, and that unless we are careful, their beneficial effects will run out. We have become so accustomed to the availability of antibiotics that a world without them is almost inconceivable. Yet this is the world that England’s chief medical officer, Sally Davies, demands we contemplate in the second volume of her annual report (doi:10.1136/bmj.f1597). The causes of this unfolding catastrophe are many: overuse of existing antibiotics, increasing resistance to them, a “discovery void” regarding new drugs, and a change in the types of organisms presenting the greatest threat. “If we don’t get this right we will find ourselves in a health system not dissimilar to the early 19th century,” she says.

Is Davies being overdramatic? Sadly not. Her decision to focus on antimicrobial resistance has been broadly welcomed. And this week we publish a report from Richard Smith and Joanna Coast, long term analysts of the economics of resistance (doi:10.1136/bmj.f1493). They suggest that the picture she paints may even be too rosy. “Resistance is said to present a risk that we will fall back into the pre-antibiotic era,” they say. “However, this is perhaps optimistic.”

Their argument is that we have badly underestimated the cost of resistance. Studies that have tried to estimate the economic impact have looked at the extra cost of treating a resistant infection compared with a susceptible one. But this ignores the bigger picture. The whole of modern healthcare, including invasive surgery and immunosuppressive chemotherapy, is based on the assumption that infections can be prevented or treated. ”Resistance is not just an infectious disease issue,” they say. “It is a surgical issue, a cancer issue, a health system issue.”

Their revised assessment of the economic burden of resistance encompasses the possibility of not having any effective antimicrobial drugs. Under these circumstances they estimate that infection rates after hip replacement would increase from about 1% to 40-50%, and that about a third of people with an infection would die. It seems likely that rates of hip replacement would fall, bringing an increased burden of morbidity from hip pain.

The CMO’s 17 recommendations include better hygiene measures and surveillance, greater efforts to preserve the effectiveness of existing drugs, and encouragement to develop new ones. As Anthony Kessel and Mike Sharland point out, only one or two new antibiotics that target Gram negative organisms are likely to be marketed in the next decade (doi:10.1136/bmj.f1601). Recognising this as a global problem, the CMO’s report also calls for antimicrobial resistance to be put on the national risk register and taken seriously by politicians internationally.

As for the cost of such action, Smith and Coast see it as an essential insurance policy against a catastrophe that we hope will never happen. And they share the CMO’s urgency. “Waiting for the burden to become substantial before taking action may mean waiting until it is too late.”

NICE approves eye drug for diabetes

A drug that can save the sight of people with diabetes may now be made available on the NHS in England and Wales – reversing an earlier decision.

At least 50,000 people in the UK have diabetic macular oedema which can leave people unable to read, work or drive.

In 2011, the National Institute for Health and Clinical Excellence (NICE) said ranibizumab, which is sold as Lucentis, was too expensive.

A final decision will be made in February.

Macular oedema occurs when fluid leaks from the small blood vessels in the eye.

Diabetes can trigger changes to the blood vessels leading to fluid collecting in the central part of the retina called the macular area.

Saving sightProf Carole Longson, from NICE, said the manufacturers had agreed to reduce the price which led to a review of the guidance.

“NICE is pleased to recommend ranibizumab as a treatment option for some people with visual impairment caused by diabetic macular oedema in new draft guidance.”

Clara Eaglen, eye health policy and campaigns manager at the charity RNIB, said: “We believe NICE has thrown a lifeline to the growing number of people with diabetes facing blindness.

“Currently people are needlessly losing their sight from diabetic macular oedema.”

Barbara Young, the chief executive of Diabetes UK, said: “We are delighted that NICE have reconsidered their previous decision, and that this draft guidance recommends that Lucentis is made available on the NHS, as this would mean more people with diabetes would have a better opportunity to preserve and possibly improve their vision.”

Arriving in a train station in a Northeast city the other day, I was struck by the number of advertisements for proton therapy at a local academic medical center (AMC) plastered throughout the station and in local subways. The ads feature a bicycle racer with the tag line: “THE WIND IN YOUR FACE IS WORTH PROTON THERAPY: A cancer treatment that has fewer side effects.”

A bold statement, I thought, considering several studies have shown that proton therapy provides no long-term benefit over traditional radiation and comes with significantly higher cost for most conditions. There are a limited number of conditions—such as pediatric oncology—where proton therapy is shown to be effective. Most striking, however, was the fact that this ad was specifically created to target a public that is not aware of the proton therapy’s marginal benefit and in what limited conditions it is effective.

“Marginal benefit” is when two procedures have small differences in benefits but large cost differences. Usually the more expensive intervention yields more benefits, like fewer side effects. But in this case, we have a procedure with no added benefits that is a lot more expensive.

Proton therapy uses atomic particles to treat cancer rather than X-rays. The particle accelerator is the size of a football field and costs about $180 million. According to the Yale study, Medicare pays over $32,000 for the treatment compared to under $19,000 for radiation. When applied to treat prostate cancer, outcomes were no different than intensity-modulated radiotherapy. Urinary function side effects were slightly better within six months but those advantages disappeared with 12 months post-therapy.

The ad directly contradicts the findings of this study and claims that proton therapy has fewer side effects than traditional therapy. This claim is true for pediatric cases but not for prostate cancer, the one primarily targeted by these ads.

What bothers me the most is that an AMC is peddling a more expensive procedure with no clear added benefit to the public through a massive advertising campaign. Isn’t there a moral imperative for an AMC to work in the best interest of their community based on the best available clinical evidence? Isn’t this supposed to be the era of value services? If they must advertise the therapy (possibly to recoup some of their costs or at least break even), why not target referring physicians rather than an unsuspecting public that is prone to request the latest and greatest technology just because it’s new? Perhaps referring physicians are wise to the lack of proton therapy’s marginal benefit and the AMC is hoping they will acquiesce to their patients’ demand for this marginal procedure. Is the public to know what cases are best for this type of therapy and for which conditions it is not well suited?

We should expect more and we should demand better. Proton therapy is clearly a more expensive procedure where a just-as-effective procedure exists. Quality and safety has not been raised, only the cost of medicine.